In Cancer and Beyond, Washington State Making the Transition to Value- Based Care

Mary K. Caffrey

Few places put as much emphasis on value-based healthcare as Washington state does. From a governor whose workplace wellness program for state employees requires progress reports every 6 months,1 to the Health Care Authority’s quest for $51 million from the federal government to revamp Medicaid delivery,2 words like “prevention” and “outcomes” populate every message.

Healthcare reform, as envisioned by the 2010 Affordable Care Act, was a process both the former and current governors fully embraced. Like his counterpart in Kentucky, Washington Governor Jay Inslee presents the expansion of coverage as both a moral imperative and competitive necessity; he says the ACA rollout “has presented us with the ideal opportunity to implement the

kinds of costsaving, health-improving reforms that will help us achieve those goals.”3

In the realm of cancer care, Washington state’s relative success in adding nearly 250,000 to the ranks of the insured by January 1, 2014,4 including 121,258 adults previously not eligible for Medicaid,4 would seem to put the state on a course of continuing its better-than-typical response to the disease. Washington’s early enrollment numbers, along with the governance and performance of its exchange, have put it among a handful of states receiving good reviews in the ACA rollout.5

Data from 2010 show Washington’s cancer story is mixed. It is among the top 10 states in the nation for cancer incidence, at 472.2 cases per 100,000, compared with 445.5 nationally. But its death rates are lower: 169.6 per 100,000, compared with 171.8 nationwide, according to the Centers for Disease Control and Prevention (CDC). Except for slightly elevated rates of melanoma, the types of cancer seen in Washington mirror the nation’s (see Figure).6

In 2001, Washington formed the Comprehensive Cancer Control Partnership and has a statewide blueprint, the Washington State Comprehensive Cancer Control Plan, which is updated every

4 years. Prevention and screening are emphasized, and both are a natural for a culture with greater focus on fitness and health than some parts of the country. Still, Washington state has issues with disparities; low-income pockets suffer higher rates of cancer, and tribal and rural health merited special notice throughout the Health Care Authority’s recent federal grant application.2 Tobacco use is common among lower-income groups, and Native Americans suffer high rates of lung cancer, for example.7

There’s a new concern, too. A reorganization of state funding for healthcare programs generally will mean a phaseout of state funding to Washington’s Breast, Cervical and Colon Health Program (BCCHP), which through the end of 2013 provided free screening for these diseases to low-income residents. Women diagnosed with cancers were moved immediately into treatment.8

As of January 1, 2014, Washington’s BCCHP is still screening some patients, but the potential for gaps exists, according to Megan Celedonia, program manager. Those screened and diagnosed with cancer no longer have access to the companion treatment program, and BCCHP can no longer screen patients with insurance. About 75% of the program’s former target population will be eligible for Medicaid under ACA. The rest would have to sign up for subsidized coverage, but Celedonia cautions that not all will be eligible, and some will not have funds

to enroll.

“We can’t expect that all will enroll on to insurance programs immediately,” Celedonia said. “We expect that our clients will continue to need our program. Some will be diagnosed and will need

access to treatment. We need safety net services.”

A Transition to Value-Based Care

Is the phaseout of the screening program an anomaly in a state that, from all other appearances, puts a high value on healthcare? Or is this what the transition of healthcare reform is all about:

Moving the population away from the mind-set of safety net “services” into one in which being insured is the safety net?

What’s evident is that Washington state is in the process of embracing value-based care, of which the expansion of coverage under the ACA is merely a part. In December, Washington’s

Health Care Authority, which runs Medicaid and other state healthcare programs, unveiled its State Innovation Plan,2 a venture that involved multiple agencies and Governor Inslee’s office.

• promote better healthcare IT. For cancer, this will include basic items like ensuring that tumor data from Washington’s rural counties are reported to the National Cancer Institute’s Surveillance, Epidemiology and End Results program. A map for 2010 had no data from the eastern counties

In rolling out their plan, officials from Washington’s Health Care Authority vowed that whatever the result of their pursuit of the grant, the commitment to value-based healthcare is here to stay. “We’re getting geared up for implementation efforts with or without federal dollars arriving,” Nathan Johnson, director of healthcare policy at the HCA, told a Puget Sound publication.9

Some insurers like Group Health Cooperative, which accounts for about 10% of the state’s market share, already take value-based practices quite seriously; Melinda Hews, executive director, health insurance exchanges, at Group Health, said all members, regardless of how they access Group health coverage, “receive care through a capitated medical home model.” (E-mail communication, January 2014.)

In the first year of benefit design, not all insurers are as advanced, but Hews expects this will change. “I think this will mature in subsequent years as new pay-for-performance models of provider contracting gain traction and benefits may be designed differently to support that,” Hews said.10

Commitment to Clinical Pathways

If Washington state’s efforts take hold, more cancer care will be delivered the way it is within the Group Health Cooperative, which covers 600,000 people in Washington and Idaho.10 The cooperative’s use of clinical pathways has a national reputation, one that Eric Chen, MD, PhD, a medical oncologist who practices within the plan, appreciates not only for its ability to deliver good care but for his ability to help his patients understand their disease.

The pathways approach created evidence- based treatment approaches that go beyond therapies that are approved by the US Food and Drug Administration (FDA) or within guidelines of the National Comprehensive Cancer Network (NCCN). Pathways prevent outliers from allowing poor quality care or driving up costs unnecessarily.

“If there is a new standard of care, we can implement something so that everyone does the same thing,” Chen said. “It’s very easy for everyone to get on the same page.” He said pathways help doctors and payers overcome the “inertia” that works against doing things differently.

Chen has spent his entire post training career practicing medicine this way; to him, it allows the best therapies to rise to the top without external pressure. He knows, however, that not everyone

agrees.

“There are people who criticize pathways; they say, ‘that’s robot medicine.’ There’s a lot in medicine that we can do by algorithm, but the algorithm can only carry you so far. It takes a human being to make the decisions,” Chen said.

Creating Value in Being Covered

Getting people to see the value proposition of being insured is going to take time, and it’s going to take education, according to Michael Marchand, communications director at the Washington State Health Benefit Exchange. Marchand spoke to Evidence-Based Oncology last fall, after surveying Washington’s experience compared with the first rocky weeks of the federal website, healthcare.gov. He attributes Washington’s early success to strong bipartisan leadership that recognized the state would be best served if it tailored an exchange to its unique qualities. Given its workforce, that meant creating a user experience that didn’t feel like government.

Marchand said Washington’s exchange creators made a key decision to reject a recommendation from a technology conference—attended by all the major exchanges including healthcare

.gov—to require users to register before they could browse for coverage. “That single recommendation drove a lot of the decision making for healthcare.gov,” Marchand said. “We chose to ignore it…We wanted to set up a consumer experience more like Amazon.com.”

In the first few weeks, Washington saw 17% of the purchasing among consumers aged 55 to 64 years, which did not surprise Marchand at all. “These are people who have been insured at some other point in their life. They probably need it, so they are the quickest to react,” he said. Many of the so-called “young invincibles” will wait until the last minute before penalties begin this spring, because that’s “human behavior.”

“Insurance isn’t top of mind—until you get sick. Then, it’s important,” Marchand said.

To change that mind-set, Washington state’s exchange staff meet with small businesses to link healthcare reform to economic health. Being insured goes hand-in-hand with being productive,

Marchand said; there’s nothing wrong with getting insurance at your job, but if that’s the only place you can get it, it limits self-employment and entrepreneurship. Washington state is creating a system that will allow its “start-up” mentality to flourish, he said, because small businesses will have a way to cover employees that did not previously exist.

Washington state’s strong start has been helped by community support, Marchand said. Ten lead organizations, 1400 in-person assisters (or navigators), 2000 agents and brokers, and scores of customer service personnel have all done their part to get the process off the ground, he said. “I have never seen anything like it,” said Marchand, who has worked in healthcare for a long

time.

“People understand that if you have healthcare, it helps with everything. Everyone wins when people are insured,” he said. “We all benefit as a state, and as a society if people can have healthcare.” EBO

8. Washington State Department of Health. Impact of Health Reform on the Breast, Cervical, and Colon Health Program. https://www.citrinehealth.org/images/PDF/BCCHP/Partner_Training/HCRandBCCHP-FactSheet-Print.pdf. Published August 2013. Accessed January 14, 2013.